Management of acne

Early assessment of disease severity will aid the selection of suitable therapies, explains Clive Tubb.

Acne vulgaris: estimates suggest 1.7million people in the UK receive or require treatment for acne
Acne vulgaris: estimates suggest 1.7million people in the UK receive or require treatment for acne

Acne vulgaris is a common disorder affecting the face, chest and back. It is most frequently seen in adolescents. Estimates suggest 1.7 million people in the UK receive or require treatment for acne at any one time.

This chronic inflammatory disease of the pilosebaceous units is characterised by seborrhoea, formation of comedones, erythematous papules and pustules and, less frequently, by nodules, deep pustules or pseudocysts. In some cases there may be extensive scarring.

Assessing disease severity
Assessing the severity will aid the selection of suitable therapies and evaluating the response to treatment. Using an assessment tool such as the Leeds acne grading system,1 which provides a visual comparison, can enable a more standardised approach to physical severity.

The longer acne is left untreated, the greater the risk of physical and psychological scarring. Patients with acne often feel unattractive and have low self-esteem. It is important that adequate time is available for them to discuss these issues.

Physical severity of disease and psychological effects do not necessarily correlate; consider psychological disability in all patients, regardless of disease severity. Most treatments take six to 12 weeks to produce maximum effect.

With topical treatments, suggest use of moisturisers to combat any associated dryness. It is also advisable to use sunscreen, since some of the topical preparations sensitise skin.

As with many conditions, stress can worsen acne and advice should be offered on management strategies. Patients can be reassured that there is no evidence to suggest acne is caused by poor diet or hygiene and it is not contagious.

Topical treatments
Benzoyl peroxide is a mildly bactericidal keratolytic agent that is one of the most effective treatments for mild to moderate acne. It is available as a cream, gel, aqueous gel or lotion in concentrations of 2.5 per cent to 10 per cent. Both comedones and inflamed lesions respond well.

Begin with lower concentrations and titrate up if required and tolerated. There is insufficient evidence to evaluate the efficacy of different formulations. Benzoyl peroxide can help to prevent or eliminate the development of Propionibacterium acnes resistance; it is often used with oral or topical antibiotics.2

Adverse effects include local skin irritation, particularly when therapy is initiated, but scaling and redness subside with treatment continued at a reduced frequency of application (for example, application on alternate days rather than daily).

Azelaic acid has antimicrobial and anticomedonal properties. It could be an alternative to benzoyl peroxide or to topical retinoids for treating mild to moderate acne, particularly of the face. Some patients prefer this treatment because it is less likely to cause local irritation than benzoyl peroxide.

The effectiveness of topical retinoids in the treatment of acne is well documented. These agents reduce obstruction of the follicle and are useful in the management of both comedonal and inflammatory acne.

There is no consensus about the relative efficacy of available retinoids. The concentration and/or vehicle (for example, cream or gel) may affect tolerability.2 Patients should be warned of possible irritation, particularly on exposure to the sun. Retinoids are teratogenic and female patients should be advised accordingly.

Systemic therapy
Oral antibiotics remain a highly favoured and widely used treatment for acne. Antibiotics are active against P acnes and also have a direct anti-inflammatory effect.3

Antibiotic therapies include oxytetracycline, doxycycline, lymecycline and erythromycin. Use may be limited by side-effects and GI upset. If minocycline is continued for longer than six months, patients need to be monitored every three months for hepatotoxicity, pigmentation and systemic lupus erythematosus. If these develop, treatment should be discontinued.

The usual recommended dose of oxytetracycline or tetracycline is 500mg twice daily. After three months' therapy the dose may be reduced if the desired clinical effect is obtained.

Doxycycline, lymecycline and minocycline are recommended with one capsule per day dosage, which is convenient for patients and improves compliance.

Maximum improvement is expected after four to six months, but some patients may need longer courses. Tetracycline and oxytetracycline need to be taken on an empty stomach because absorption is reduced by food. Tetracyclines cannot be used in pregnancy; erythromycin is an alternative.

There is a link between the presence of antibiotic-resistant P acnes and clinical response to treatment with erythromycin and tetracyclines. Antibiotic resistance should be considered as a contributory factor to, or cause of, therapeutic failure.4

Antiandrogen therapy may be used for females with severe acne, particularly if oral contraception is required.

It works by reducing sebum production. The preparation of choice is co-cyprindiol (cyproterone acetate/ethinylestradiol). Check for a history of thromboembolism before starting; such treatment should be avoided in women who smoke, are over 35 or are hypertensive.

Topical agents such as retinoids and benzoyl peroxide can be used in combination with oral/topical antibiotics.

This strategy can increase clearance rate and reduce antibiotic resistance.3 It is appropriate for moderate papular/pustular acne. Topical retinoids can also be used as maintenance therapy.

There are ready-made combined topical preparations, including a combination of benzoyl peroxide and clindamycin.

When using these products there is no need to combine with an oral antibiotic, but they could be combined with a topical retinoid or retinoid-like treatment.

Both topical products should not be used simultaneously - the topical retinoid should be used in the morning and the benzoyl peroxide preparation at night.

When to refer
It is recommended that therapies for acne are reviewed every six to 12 weeks. If there is poor response to initial therapy it is important to check patient compliance.

If there is no response despite good compliance then alternative treatment should be sought. If there continues to be a poor response after six months it could be appropriate to refer the patient to specialist dermatologist services.

In the cases of scarring (conglobate) acne, refer to secondary care for consideration of oral isotretinoin because scarring can worsen if there is a poor response while under review with initial therapies.

  • Clive Tubb is a clinical nurse specialist in dermatology at the Queen's Medical Centre, Nottingham
Key points
  • Provide a clear explanation of the condition, the treatments and how they work.
  • Review therapies every six to 12 weeks to check the response.
  • Refer if a poor response to therapy continues after six months.

References

1. O'Brien SC, Lewis JB, Cunliffe WJ. The Leeds revised acne grading system. J Dermatol-og Treat 1998; 9: 215-20.

2. Strauss JS, Krowchuk DP, Leyden JJ et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56: 651-63.

3. Poyner T. How do we manage acne. Kent: Magister Consulting; 1999.

4. Boston M, Preston D. Acne rosacea. In: Hughes E, Van Onselen J (eds.) Dermatology nursing: a practical guide. London: Churchill Livingstone; 2001.

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